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Home My WebLink AboutAAHH-Roma 4/22/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: TEMPORARY FOOD PERMIT- NEFFA In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. SUE LUPI (CO-OWNER) Whose place of business is: AAHHH-ROMA LLC - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE: SUE LUPI (CO-OWNER) Permit Expires: April 22, 2018 Food Fee: $75.00 License Number: NEFFA-1 BOARD OF HEALTH 34ichaeC%1cCCean, Chairman FOR BOARD OF HEALTH USE ONLY FFDateReceived Permit Fee Approved By Permit # Issued Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: Aahhh-RomaLLC r------.--. 2) Establishment Address: 92 Hamilton Avenue Quincy, MA 02171 ' �r.ry 3 i 3) Establishment Mailing Address (if different): d 6 4) Establishment Telephone No: 617.462.3352 5) Applicant/Owner Name & Title: Sue Lupi / Co -Owner 6) Applicant/Owner Address: 92 Hamilton Avenue Quincy, MA 02171 7) Applicant/Owner Telephone No: 617.462.3352 8) Applicant/Owner Email address: aahhhroma@gmail.com 9) Person Directly Responsible For Onsite Operations: Name & Title: Sue Lupi / Co -Owner Address: 92 Hamilton Avenue Quincy, MA 02171 Telephone No: 617.462.3352 Fax: Emergency Telephone No: 617.462.3352 10) Event Attending Date(s): April 20 - 23, 2018 Event Name: New England Folk Festival Event Location: Mansfield High School and Mansfield Middle School Event time: Saturday noon - 9pm; Sunday noon - 5pm 11) Check one [X Food Truck ❑ Caterer ❑ Other: 12) Solid waste disposal plan: Take Home 13) Water Source: 5 gallon water tank 14) Sewage disposal plan: Take Horn 15 ) Please give a brief description of the food to be served: Pizza with toppings; soda; water 16 ) Food will be prepared: L� Onsite for immediate consumption Li Onsite and held at proper hot/ cold holding temperatures ❑ Offsite and held at proper hot/ cold holding temperatures ❑ Offsite, cooled and reheated on site ❑ Other: 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: E '6 Food Safety Manager: Sue Lupi / Steve Stanley cY Allergen Awareness: Sue Lupi / Steve Stanley 18) For caterers: CitylTown where food establishment permit is held. Please attach a copy of the caterer's permit: For food trucks, please list additional communities where a food permit is held and attach copies of the permits: I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 10 CMR 590.00 nd alother applicable law. I have been instructed by the board of health on how to obtain co es of 105 C 590.0 and the fideral Food Code. 19) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 20) Social Security Number or Federal ID: 21) Signature of Individual or Corporate Name: Food Protection Questionnaire for Catered Events Date of Event: April 20 - 23, 201 s Event Time: _ Location of Event: Mansfield High School and Mansfield Middle School Saturday noon - 9pm; Sunday noon - 5pm List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating toppings dough pizza Food Manager Certification Person Trained On Site? [� Yes ❑ No Allergen Awareness Menu Label Present? CR Yes ❑ No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: toppings < 41 degrees dough <41 degrees List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41 °F? Refrigeration How will the PHF be kept at or above 140°F? oven Time of PHF? Setup Served Removed List all equipment that will be supplied for an event, including but not limited to food thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc. food thermometers food safe gloves Sanitizers Food prep table refrigerator oven TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Si ature of Individual or Corporate Name 45-4779409 **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name Address: 92 Hamilton Avenue City/State/Zip: Quincy, MA 02171 Aahhh-Roma LLC Phone #: 617.462.3352 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time). * 6. ❑ Restaurant/Bar/Eating Establishment 2. [XI am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* I1.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #t must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Nan Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. Expiration Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, u der the pain nd p tallies ofperjury that the information provided above is true and correct Sign e: Date: Z 7.462.3352 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. 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